The practical nurse (PN) reviews the history of an older adult who is newly admitted to a long-term care facility. Which factor in the resident's history should the PN consider the most likely to increase the client's risk for falls?
Ankle ulcer that is healing slowly.
History of alcohol abuse and cigarete smoking.
Recent weight gain of twenty pounds.
Newly prescribed antihypertensive medication.
The Correct Answer is D
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
A. An ankle ulcer that is healing slowly is not a major risk factor for falls and may not affect the client's mobility or balance.
B. History of alcohol abuse and cigarette smoking is not a major risk factor for falls unless the client is currently intoxicated or has a chronic lung disease that impairs oxygenation or cognition.
C. Recent weight gain of twenty pounds is not a major risk factor for falls unless it causes joint pain, edema, or difficulty moving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Step 1: 1 gram = 1000 mg
Step 2: 500 mg ÷ 1000 mg = 0.5
Step 3: 0.5 × 3.0 mL = 1.5 mL
Answer: 1.5 mL
Correct Answer is C
Explanation
The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.
Choice A rationale:
Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.
Choice B rationale:
Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.
Choice C rationale:
Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.
Choice D rationale:
Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.
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